BreastCancer - Hypothetical Chief Complaint Hypothetical I...

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Hypothetical Chief Complaint Hypothetical Chief Complaint “ I have left nipple swelling”
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History of Present Illness History of Present Illness 75 y.o. male was noted to have a painful left nipple swelling on 3/15/06. The nurse noted that it was an easily palpable lump, with tenderness upon palpation. A surgical consult was sought, and suggested to perform mammogram and ultrasound.
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Past Medical History Dementia HTN GERD Past Surgical History s/p cholecystectomy s/p peg (12/05)
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Medications Medications Metoprolol 25 mg BID Senna 8.6 mg QHS Ranatidine 150 mg BID Seraquil 25 mg BID Aricept 5 mg QHS Tyenol 160mg/5mL Q 6 hours (PRN) MVI
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Allergies: NKDA Social History: No smoking, drinking, or drugs Family History: No history of cancers
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VS: T: 98.2 P: 80 RR: 16 BP: 100/50 Gen: AAO x 3, NAD HEENT: NC/AT, PERRLA, EOMI, no LAD, OP clear Neck: supple, no thyromegaly Chest: CTA b/l, + aw entry, + left breast mass, palpable at about 12 o’clock, + tenderness on palpation CV: S1S2 nl, RRR Abd: soft, NT/ND, + BS, no HSM Extremities: WINL Neuro: no focal neurological deficit, AAO x 3
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Labs Labs WBC: 7.9 Mg: 1.8 H/H: 11.7/39.8 Phosphorus: 2.8 Platelets: 275 Coags: 11.2/25.4/.7 Na: 139 CXR: NAPD K: 4.1 EKG: NSR @ 100 BPM Cl:107 HCO3: 29 BUN: 25 Cr: 0.9 Glucose: 78 Ca: 8.9
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Radiographic Labs Radiographic Labs Mammogram Right breast is fatty with some retroareolar densities probably representing mild gynecomastia Density of left breast, which can represent gynecomastia, but mass can’t be excluded U/S indicated and open excision Impression: Changes consistent with gynecomastia R/O mass in left breast approximately at 2 o’clock BI-RADS Score Right breast: # 2 Left breast: #0
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Radiographic Labs Radiographic Labs Ultrasound of Left Breast In the periareolar region at 12 o’clock, 1-2, 3, 4-5 and 6 positions, hypoechoic density is seen, some borders have mass effect. There is a slight vascularity within the lesion, which measures 1.5 x .69 cm in the radial plane and 1.49 cm in the anteradial plane Some compression is seen consistent with gynecomastia BI-RADS Score: Left Breast: #3
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Radiographic Labs Radiographic Labs Left Core Biopsy of Breast Mass Breast tissue showing extensive foci of atypical ductal hyperplasia in the background of gynecomastia.
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Breast Cancer Breast Cancer Marcella A. Escoto Marcella A. Escoto St. Barnabas Scholar St. Barnabas Scholar MS III MS III
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Breast Cancer Breast cancer is the most common female cancer in the U.S. It is the second most common cause of cancer death in women. Lastly, it is the main cause of death in women
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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BreastCancer - Hypothetical Chief Complaint Hypothetical I...

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